What is the recommended treatment for an anxiety disorder?

Treatment Recommendations for Anxiety Disorders

Start with either an SSRI (sertraline 25-50 mg daily or escitalopram 5-10 mg daily) or individual cognitive behavioral therapy (CBT) as first-line treatment, with combination therapy providing superior outcomes for severe cases. 1, 2

First-Line Pharmacotherapy

SSRIs are the preferred initial medication class with established efficacy across anxiety disorder subtypes 3, 1, 2:

• Sertraline is a top-tier first-line agent: start at 25-50 mg daily, titrate by 25-50 mg every 1-2 weeks as tolerated, targeting 50-200 mg/day 1, 4
• Escitalopram is equally preferred: start at 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day 1, 4
• These two agents have superior tolerability profiles and lower discontinuation symptom risks compared to paroxetine or fluvoxamine 1

SNRIs serve as effective alternatives when SSRIs are not tolerated or preferred 3, 1:

• Venlafaxine extended-release 75-225 mg/day is effective for generalized anxiety disorder, social anxiety disorder, and panic disorder 3, 1, 4
• Duloxetine 60-120 mg/day offers additional benefits for patients with comorbid pain conditions 1
• Monitor blood pressure with venlafaxine due to risk of sustained hypertension 1, 4

Expected Response Timeline

• Statistically significant improvement begins by week 2 1
• Clinically meaningful improvement occurs by week 6 1, 4
• Maximal therapeutic benefit achieved by week 12 or later 1, 4
• Do not abandon treatment prematurely—full response requires patience 1

Common Side Effects to Anticipate

Most adverse effects emerge within the first few weeks and typically resolve with continued treatment 1:

• Nausea, sexual dysfunction, headache, insomnia 1
• Dry mouth, diarrhea, heartburn, somnolence, dizziness 1
• Critical warning: Monitor for suicidal thinking and behavior, especially in the first months and following dose adjustments (pooled risk 1% vs 0.2% placebo, NNH=143) 1

First-Line Psychotherapy

Individual CBT specifically designed for anxiety disorders is the psychotherapy with the highest level of evidence 3, 1, 2:

• Individual sessions are prioritized over group therapy due to superior clinical and cost-effectiveness 3, 1
• For social anxiety disorder, use protocols based on the Clark and Wells model or Heimberg model 3, 4
• CBT should include: education on anxiety mechanisms, cognitive restructuring to challenge distortions, relaxation techniques, and gradual exposure to feared situations 1
• Structured duration of 12-20 sessions achieves significant symptomatic and functional improvement 1
• If face-to-face CBT is unavailable or not desired, self-help CBT with professional support is a viable alternative 3, 2

Combination Therapy Approach

For severe anxiety or inadequate response to monotherapy, combining medication with CBT provides superior outcomes 1, 5:

• While guidelines note insufficient evidence to formally recommend combination therapy for social anxiety disorder specifically 3, 4, the broader evidence supports combined treatment for optimal results in anxiety disorders generally 1, 5
• CBT demonstrates large effect sizes for generalized anxiety disorder (Hedges g = 1.01) 1, 5

Treatment Algorithm for Inadequate Response

If inadequate response after 8-12 weeks at therapeutic doses 1:

1. Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) 1
2. Consider adding CBT if not already implemented 1
3. Trial an SNRI (venlafaxine or duloxetine) as second-line pharmacotherapy 1
4. Consider pregabalin/gabapentin when first-line treatments fail, particularly with comorbid pain 1

Treatment Duration

• First episode: Continue medication for at least 4-12 months after symptom remission 2, 6
• Recurrent anxiety: Longer-term or indefinite treatment may be beneficial 2
• Discontinue gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs 1
• Reduce by no more than 25-50% of dose every 1-2 weeks 1

Medications to Avoid

Benzodiazepines should be reserved for short-term use only due to risks of dependence, tolerance, and withdrawal 1, 4:

• While alprazolam is FDA-approved for anxiety and panic disorder 7, guidelines consistently recommend against routine use 1, 4
• Maximum short-term use only in acute situations while initiating definitive treatment 1

Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 1, 4

Beta-blockers (atenolol, propranolol) are not recommended for social anxiety disorder based on negative evidence 1, 4

Adjunctive Non-Pharmacological Strategies

Useful alongside primary treatment 1:

• Breathing techniques, progressive muscle relaxation, grounding strategies 1
• Mindfulness and visualization exercises 1
• Regular cardiovascular exercise provides moderate to large reduction in anxiety symptoms 1
• Psychoeducation for family members about anxiety symptoms and treatment 1

Special Considerations for Elderly Patients

• Sertraline and escitalopram are preferred due to lower potential for drug interactions 2
• Avoid paroxetine and fluoxetine in older adults due to higher rates of adverse effects 2